Risk Adjustment Coding and HCC Guide

1 Power up your Adjustment Coding and HCC Guide2018 Optum360, LLCiContentsIntroduction .. 1 History and purpose of RAF ..1 Key Terms Definitions ..3 Acceptable provider types/SOS ..5 The provider s role ..6 Payment Methodology ..8 RAF Payment Timeline ..12 Coding and Documentation ..15 Explanation of impact of good documentation (table example).. 15 CMS 20 Coding Guidelines .. 44 Tools (MEAT/TAMPER) .. 48 Coding Scenarios/Examples/Teaching .. 59 Audits .. 79 Medicare Advantage Risk Adjustment Data Validation (RADV) .. 79 Health Effectiveness Data & Information Set (HEDIS) .. 87 Internal Care and Quality Improvement Audits ..91 Care and Quality Improvement Audits .. 91 Appendixes - Includes HCC with description, hierarchies, and ICD-10 Mappings .. 103 CMS HCCs .. 105Rx HCCs .. 395 PACE .. 445 HHS-HCC .. 495 RAF weights tables .. 5352018 Optum360, LLC1 IntroductionThe traditional fee-for-service payment model has been widely used since the 1930s when health insurance plans initially gained popularity within the United States.

2 In this payment model, a provider or facility is compensated based on the services provided. This payment model has proven to be very expensive. Closer attention is being paid to healthcare spending versus outcomes and quality of care, and this has been compared to the healthcare spending of other nations. This has caused a need to develop a system to evaluate the care being the 1970s, Medicare began demonstration projects that contracted with health maintenance organizations (HMOs) to provide care for Medicare beneficiaries in exchange for prospective payments. In 1985, this project changed from demonstration status to a regular part of the Medicare program, Medicare Part C. The Balanced Budget Act (BBA) of 1997 named Medicare s Part C managed care program Medicare+Choice, and the Medicare Modernization Act (MMA) of 2003 again renamed it to Medicare Advantage (MA). Medicare is one of the world s largest health insurance programs, and about one-third of the beneficiaries on Medicare are enrolled in a MA private healthcare plan.

3 Due to the great variance in the health status of Medicare beneficiaries, risk Adjustment provides a means of adequately compensating those plans with large numbers of seriously ill patients while not overburdening other plans that have healthier individuals. Medicare Advantage plans have been using the Hierarchical Condition Category (HCC)/risk Adjustment model since 2004. The primary purpose of a risk Adjustment model is to predict (on average) the future healthcare costs for specific consortiums enrolled in MA health plans. CMS is then able to provide capitation payments to these private health plans. Capitation payments are an incentive for health plans to enroll not only healthier individuals but those with chronic conditions or who are more seriously ill by removing some of the financial burden. The MA risk Adjustment model uses HCCs to assess the disease burden of its enrollees. HCC diagnostic groupings were created after examining claims data so that enrollees with similar disease processes, and consequently similar healthcare expenditures, could be pooled into a larger data set in which an average expenditure rate could be determined.

4 The medical conditions included in HCC categories are those that were determined to most predictably affect the health status and healthcare costs of any individual. Section of 1343 of the Affordable Care Act of 2010 provides for a risk Adjustment program for non-Medicare advantage plans which are available in online insurance exchange marketplaces. Beginning in 2014, commercial insurances were able to potentially mitigate increased costs for the insurance plan and increased premiums for higher-risk populations such as those with chronic illnesses by using a risk Adjustment model. The risk Adjustment program developed for use by non-Medicare plans is maintained by the Department of Health and Human Services (HHS). This model also uses HCC diagnostic groupings; however, this set of HCCs differs from the CMS HCCs to reflect the differences in the populations served by each healthcare plan publication will cover the following: History and purpose of RAF Key terms definitions Acceptable provider types Payment methodology and timeline Coding and documentation Tools for risk Adjustment Coding scenarios Guidance for developing internal risk Adjustment Coding polices Audits HEDIS Risk Adjustment tablesRisk Adjustment Coding and HCC Guide2018 Optum360, LLC59 Coding Scenario 1 Patient Name: Betty SmithElectronically Signed: Dr.

5 B. Johnson, : 07/28/1963 Appt. Date/Time: 4/5/2017 Insurance: Medicare Advantage (HMO)Appt. Type: MCEC hief Complaint: Follow up hyperlipidemia, HTN, OA, MDDV italsBP: 134/71 sitting L armBP Cuff Size: adultPulse: 61 bpm regularT: F oralO2 Sat: 93% RAHt: 62 inW: 200lbs BMI: ROSP atient reports no frequent nosebleeds, no nose problems, and no sinus problems: congestion. She reports dry mouth but reports no sore throat, no bleeding gums, no snoring, no mouth ulcers, and no teeth problems. She reports arthralgia/joint pain (right knee) but reports no muscle aches, no muscle weakness, no back pain, and no swelling in the extremities. She reports frequent or severe headaches but reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, and no tremor. She reports fatigue. She reports no fever, no night sweats, no significant weight gain, no significant weight loss, and no exercise intolerance. She reports no dry eyes, no vision change, and no irritation.

6 She reports no difficulty hearing and no ear pain. She reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, and no known heart murmur. She reports no cough, no wheezing, no shortness of breath, no coughing up blood, and no sleep apnea. She reports no abdominal pain, no nausea, no vomiting, no constipation, normal appetite, no diarrhea, not vomiting blood, no dyspepsia, and no GERD. She reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. She reports no abnormal mole, no jaundice, no rashes, and no laceration. She reports no depression, no sleep disturbances, feeling safe in a relationship, no alcohol abuse, no anxiety, no hallucinations, and no suicidal thoughts. She reports no swollen glands, no bruising, and no excessive bleeding. She reports no runny nose, no sinus pressure, no itching, no hives, and no frequent updated 04/05/2017 Breast cancer stable, sees oncology, on tamoxifen for 2 yearsDepressive disorder major, partially managed on SSRIOSA refuses CPAPP hysical ExamPatient is a 54-year-old Appearance: well-developed, appears stated age, and of Distress: Status: alert and normal : oriented to time, place, and person.

7 Insight: good Exam: no heaves or precordial thrills and non-displaced focal PMI. Rate And Rhythm: Sounds: no rub, gallop, or click and normal S1 and physiologically split S2. Systolic Murmur: not Murmur: not heardExtremitiesNo cyanosis, edema, or peripheral signs of emboliNeurologicMotor: tremor of neck and face and armsThe provider should also be queried for Morbid (severe) obesity with alveolar hypoventilation. The body mass index (BMI) is noted to be on the DOS and the patient has comorbidities of hypertension, hyperlipidemia, and obstructive sleep apnea (OSA).This note validates that the breast cancer is an active problem which is being treated. The provider documented that the patient is undergoing treatment with tamoxifen and is seeing an oncology provider. The history portion of this note also shows that it was updated on the date of service (DOS).Risk Adjustment Coding and HCC Guide602018 Optum360, LLCC oding Scenario 1 (continued) hyperlipidemia continue essential hypertension continue discussed sleep hygiene/caffeine continue meds/consider seeing discussed increasing activity and decreasing caloric intakeHCC CategoryICD-10-CM Code DescriptionRAF ValueValidated by Current DocumentationImproved DocumentationHCC Major depressive disorder, recurrent, in partial Malignant neoplasm of unspecified site of unspecified female Obesity hypoventilation syndrome (OHS) , female, not Medicaid is necessary to query the provider for additional information about the depression.

8 There is insufficient documentation to code major depressive Adjustment Coding and HCC Guide2018 Optum360, LLC61 Coding Scenario 2 Result type: History and Physical NotePerformed By/Author: Black MD, Brian on January 11, 2018 Result date: January 11, 2018 Verified By: Black MD, Brian on January 11, 2018 Result status: Auth (Verified)Encounter info: (IPE) Emergency - IP, 1/11/2018 - 1/12/2018 Result Title/Subject: History and Physical* Final Report *History and PhysicalPatient: MILLER, PAUL C Age: 91 years Sex: Male Associated Diagnoses: NoneDOB: 12/27/1926 Chief Complaint: slurred speech, facial droop, fallAuthor: Black, MD BrianHistory of Present Illness91 yo M PMH significant for A-fib not on anticoagulation, HTN, asthma, colon CA s/p resection 2 years prior who is BIBA f for acute onset of slurred speech, left lower facial droop following fall. Patient and wife note around 830 PM last night, he sustained a slow fall in his home. He is unsure if he lost balance but had difficulty standing back up on his own but was able to be seated into chair by his wife.

9 He then noticed that he had a difficult time speaking and his wife noted he had a left lower facial droop. She suspected he has having a stroke and gave him approximately 250 mg of Aspirin. Wife then called EMS, and patient and wife both note that his symptoms were improving already in the ambulance. Symptoms were essentially resolved by the time he arrived to the ED here, which was approximately 30 mins after onset of symptoms. He had otherwise been feeling well except for a mild cough which started about 10 days ago and has mostly resolved. He notes he was given a cough suppressant with bactrim by PCP, which he has since completed. He otherwise denies any fevers, chills, dizziness, shortness of breath, chest pain, palpitations, nausea/vomiting, bowel changes, urinary changes, blood in of Systems12 point ROS reviewed and negative except as abovePast Medical Historyas noted (1) Active Reaction: quiNIDine Affect his liverSocial Historydenies tobacco, quit in 1986denies etoh or drug useFamily Historymother- colon CABrother- throat CAHome Medications (6) Activeatenolol 25 mg oral tablet See Instructionsfinasteride 5 mg oral tablet 5 mg = 1 tab, PO, dailyloratadine 10 mg, PO, dailymultivitamin 1 cap, PO, dailytamsulosin mg oral capsule mg = 1 cap, PO, dailyUnlisted Med See InstructionsRisk Adjustment Coding and HCC Guide622018 Optum360, LLCC oding Scenario 2 (continued)Current Vitals (past 48hrs, max 5 results)Dt/Tm Temp BP MAP Pulse RR SpO2 FiO2O2 Therapy01/11/18 00.

10 30 -----122/60 81 88 18 96% -----Room air01/11/18 00:11 ----- 129/58 82 78 18 96%-----Room air01/10/18 22:45 127/7592 83 18 96%-----Room airTmax 24Hr: DegC ( DegF ) 01/10/18 22:45 (Oral)Tmax 36Hr: DegC ( DegF ) 01/10/18 22:45 (Oral)BMI: (01/10/2018 23:10)Physical ExaminationGeneral: Awake, alert, NADHEENT: Normo-cephalic, atraumatic; PERRL. Extraocular muscles are intact, sclera non-ictericNeck: Trachea midlineLungs: Clear to auscultation bilaterallyCardiac: Irregular rate/rhythm, S1 and S2 with no murmursAbdomen: Soft, non-tender and non-distended with good bowel soundsExtremities: No cyanosis or edemaSkin: No rashes or lesionNeurological: Cranial nerves II through XII grossly intact, motor- 5/5 throughout large muscle groups, sensation-intact throughout, cerebellar- finger to nose wnl, alert and oriented to person, place and timePsychiatric Evaluation: Normal mood and affect, normal judgement and insightAll Results (36 Hrs)All labs personally Results (Past 36 Hours)CT Head w/o Contrast STROKE COPerformed By/Author: Dr.